A new trend is developing relating to the outpatient management of patients with prostate cancer. The major driver is the ability to identify patients who have high-risk disease and treat them in a more aggressive way (see: U-M launches new clinic for ‘high-risk’ prostate cancer). Below is an excerpt from the article:
While every year about 30,000 men die of prostate cancer in the United States, the most common cause of death in men with prostate cancer is heart disease. That’s because not all prostate cancers are the same. Some are slow-growing while others are very aggressive. The University of Michigan Comprehensive Cancer Center has started a new clinic focused on men with the fast-growing type of cancer. This kind of high risk disease is thought to possess a high likelihood of causing harm....The clinic brings together experts in urology, medical oncology, radiation oncology and pathology. All of these specialists review cases together, discussing each patient’s unique factors and agreeing on the best treatment plan. Patients also receive free cancer genome sequencing along with several recently introduced predictive genetic tests. Clinical trials are offered when appropriate....The high-risk prostate cancer clinic also offers survivorship services, including a team of social workers and other health care providers who help patients and their families deal with the challenges that go along with a cancer diagnosis. As evidence grows that no two cancers are the same, doctors are more and more focusing on precision medicine, in which the particular genes, proteins or other markers in an individual’s tumor tell doctors what kind of drug might be more effective – and what might be less effective. It allows patients to avoid drugs that are not likely to work for them....
What is high-risk prostate cancer? Doctors start with the results of blood tests and biopsies to guide the classification of high-risk prostate cancer. The key is that these are tumors likely to return or spread and cause poor outcomes. Some of the markers that come into play include:
Gleason score (8 or more)
PSA score (20 or more)
Advanced stage (T3 or higher)
Relapse after prior surgery or radiation therapy
This report is interesting on a few counts. Recall that it's now rather common to refer to cancer as a chronic disease. By this it is meant that, for most patients, the disease can be managed well and is not life-threatening. I would amend this statement to say that cancer, except the high-risk varieties, can be treated as a chronic disease. At least at the University of Michigan, they are now separating some of these high-risk patients out into a separate clinic. This identification/separation process is accomplished with the Gleason score, PSA testing, cancer staging, and, more recently, next generation genomic screening (NGS) of the tumor tissue. Here's a quote from the article above about this latter approach: Patients also receive free cancer genome sequencing along with several recently introduced predictive genetic tests.
Several other key aspects of the special care that these high-risk prostate cancer patients receive is also mentioned in the article. The first is that they are diagnosed and treated with multidisciiplinary teams (see: Multidisciplinary Diagnostic Teams and Integrated Diagnostic Centers; Cleveland Clinic Use of Multidisciplinary Teams; Salaried Physicians Deemed Essential). The value of these MDTs is that the instincts of individual specialists (e.g., oncologic surgeons, oncologists, radiation therapists) are suppressed in favor of overall team recommendations. The second is access to survivorship services (see: Cancer Survivorship, an Emerging Subdiscipline in Oncology; Cancer Survivorship and the Role of PCPs in Continuing Care of Cancer Patients). Because these high-risk patients will be subjected to the most aggressive therapeutic regimens, there is the greatest likelihood of post-treatment complications, both medical and psychologic. Lastly, the article makes mention of precision medicine by which is meant NGS of tumor tissue to ensure that the optimal treatment is selected. This is now the preferred term over personalized medicine which is being used in a much broader way.